Relation between Severity of Symptoms, Resilience and Health-Related Quality of Life in Patients with Congestive Heart Failure

Background: Patients who have heart failure need to accept health alteration and positive coping with chronic symptoms and maintain a good health-related quality of life as guaranteeing their survival. Aim: Assess the relationship between severity of symptoms, resilience and health-related quality of life for patients with congestive heart failure. Design : A descriptive, correlational design was employed. Setting : El-Salam general hospital and Al-Nasr specialized hospital in Egypt Health care Authority hospitals in Port Said governorate. Subjects : Purposive sample of 98 patients with CHF adult patients of both sexes who agreed to participate in the research with inclusion criteria patients who had been given a one-year congestive heart failure diagnosis. Tools: Anderson Symptom Inventory, the Resilience Scale, the Patients' health-related Quality of Life, and the Patients' characteristics questionnaire. Results: The majority of the patients (66.3 %) significantly had sever level of severity and symptom interfering with patients’ life, also 42.9% of them had high level of resilience and majority of them (75.5%) had average level of total health-related quality of life . Conclusion: There is a negative correlation between the distress symptoms exhibited by the patient and their overall level of resilience, as supported by statistical analysis. Besides, a substantial negative correlation was recorded between the distress symptoms experienced by the patients and their overall health-related quality of life. Recommendations : designing and implementing intervention programs that improve patients' health-related quality of life since congestive heart failure affect their capacity for resilience.


INTRODUCTION
The morbidity and mortality rate of congestive heart failure (CHF), a complicated clinical illness that affects patients' health-related quality of life (HRQOL) internationally, is continuously rising.Patients with chronic heart failure often have IHD, hypertension, diabetes, and dilated cardiomyopathy as co-morbid conditions.Due to severe clinical symptoms such as shortness of breathing, chest pain, heart palpitations and swelling os legs, disability, and hospitalization, CHF patients have a worse health-related quality of life than the general population (Khaled, 2022).
Heart failure is a challenging clinical condition that arises from a functional or structural cardiac issue that hinders the ventricular filling or blood ejection to the systemic circulation.CHF is described as the inability to satisfy the systemic requirements for circulation (Malik, Brito, Vaqar & Chhabra, 2022).
Health-related quality of life, or HRQOL, is a multidimensional term that incorporates psychological, social, and physical functioning.Assessment of HRQOL is critical in patients with congestive heart failure(CHF) that force them to alter their regular routines or prevent them from carrying out their everyday tasks typically (Van der Plas, Schachar & Hitzler, 2018).
Resilience is described as the ability of people subjected to stressful events to sustain relatively safe and stable psychological and physical places, along with the ability to cope with new problems and obstacles and produce positive experiences despite these problems (Babanataj, Mazdarani, Hesamzadeh, Gorji, & Cherati, 2019).Resilience promotes effective adaptation mechanisms, miziminim the effects of the disease, and preserves positive moods in patients with a variety of disorders.(Rezai, Dehghanzadeh & Akbari, 2019).
The nurses have a central role in offering emotional and psychological support to patients and their families in all settings, such as supporting the patient through diagnosis and ensuring optimum care given to them.Besides the provision of technical care, nurses must have the qualified professional knowledge, attitudes and skills, providing the informational, emotional, practical supports, improving quality of care, enhancing patient safety, and providing continuity of care (Kleinpell, Grabenkort ,Kapu, Constantine, & Sicoutris, 2019).

Significance of the study
Despite the fact that many studies have focused on the patients' health-related quality of life due to congestive heart failure, more emphasis should be given to the patients' resilience and how they handle any potentially severe symptoms.(Shu, Zhang, Wu, Huang & Meng , 2019).Few studies have examined resilience in this group using validated measures, particularly when it comes to resilience linked to self-esteem, anxiety, or depression.These findings may assist the development of interdisciplinary solutions that emphasize improved emotional intelligence and resilience to help heart disease patients manage stress.(Bergh, Udumyan, Fall, Almroth, and Montgomery, 2018).

AIM OF THE STUDY
The aim of this study is to:  Assess the relationship between severity of symptoms, resilience and healthrelated quality of Life in Patients with Congestive Heart Failure

Technical Design:
It comprise the research design, setting, subjects, and data-collecting tools.

Research Design
A descriptive correlational research design was adopted, which defined as a type of research design that explain the relationship between two or more variables without making any claims about cause and effect (Fowler, 2013).

Study Setting
El-Salam general hospital and Al-Nasr specialized hospital in Egypt of Health care Authority, were the hospitals where this research was conducted in the heart outpatient clinics, cardiac care units, general care units, cardiac catheterization units and post-cath care.

Subjects
purposive sample of 98 patients with CHF adult patients of both sexes who agreed to participate in the research with inclusion criteria patients who had been given a oneyear congestive heart failure diagnosis were enrolled as study participants.And the exclusion criteria Patients with Psychiatric disorder, Obvious intellectual impairment.

The subject size was calculated according to the following estimation:
The sample population will be estimated via the following equation: Z 2 Sample Size (n) = ---------P (100 -P) (Dobson, 1984)  2 Where:

Z:
A standard normal distribution percentile calculated with a 95% confidence level = 1.96.
 : The width of the confidence interval = 10.

Tools of Data Collection
It was developed by the researcher through review of related and recent literature and aimed to assess the patients personal, and medical health data, symptoms and resilience, and health-related quality of life.It included four parts as the following:

Tool (I): patients' characteristics questioner
This tool includes two parts:

First part: characteristics of the studied patients
This part developed by the researcher and include questions related to personal data include: (patient code, age, sex, marital status, number of family members, level of education and occupational status).

Second part: past medical history and surgical history
This part includes past medical history as hypertension, diabetes mellitus, obesity, hyperlipidemia, coronary artery disease and atrial fibrillation and surgical history as heart bypass surgery, Open heart surgery, therapeutic catherization, Heart stenting and number of hospitalization due to congestive heart failure.

Tool (II): Anderson Symptom Inventory (ASI))
It was adopted from Reilly, Bruner, Mitchell, Minasian, Basch, Dueck, Cella & Reeve. 2013), it is the most widely used scale for assessing symptoms in patients with CHF and has been extensively used in the previous clinical researches.It included two subscales as the following: First section was concerned with the existence and severity of 13 symptoms as pain, fatigue, nausea, disturbed sleep, shortness of breath, etc.
Second section was concerned with how much these symptoms affects CHF patients' daily activities as: mood, general activity, walking, work (including work around the house), relation with people and enjoyment of life.
It was verified in Arabic and all items had a satisfactory internal consistency (Cronbach's alpha was.85); (Nejmi, et al., 2010).

Tool (III): The resilience scale
The tool adapted from (Wagnild & Young. 2009) which consisted of 25 items to identify the degree of individual resilience with better understanding of ability to respond during times of adversity.

Tool (IV): Patients' health-related quality of life
The instrument was modified by (Ware & Sherbourne. 1992)

II. Operational Design
It consists of a preliminary phase that addresses tool dependability, validity, a pilot study, and field work.

Preparatory phase
It began with a review of recent literature about congestive heart failure in numerous studies and a theoretical aspect utilizing books, research papers, the internet, and journals.Examining the official websites of organizations like American College of Physicians Journal Club (ACP) , Pub Med, the Cochrane Library, Ebesco.Also, the process of obtaining the preliminary approval of the medical directors of the chosen institutions began.

Validity
The researcher translated into Arabic the Anderson Symptom Inventory, the Resilience Scale, and the Patients' health-related Quality of Life.To ensure that the study tools are being measured and checked for translation, supervisors and a jury of nine experts in medical surgical nursing and cardiologists then reviewed the study tools to ensure their clarity, relevance, comprehensiveness, understanding, and applicability.
Changes were made on the advice of the experts.Within a two-week timeframe, this phase was completed.

Reliability
Through the use of Alpha Cronbach reliability analysis the results showed that each instrument had moderate to high reliability and included reasonably homogeneous items.

Tools Alpha Cronbach
Anderson Symptom Inventory (ASI) 0.897 The resilience scale 0.955 Patients' health-related quality of life (40-Item Short Form Survey) 0.918

Pilot study
It was carried out on ten cases, which represented 10% of the whole sample, and were chosen at random after the study's tools were adjusted and reviewed, and were therefore omitted from the study's overall sample.To ensure the viability, applicability, and objectivity of the research instruments, , and the modifications were done.

Field work
Once the researcher has gained approval from the directors of the mentioned study settings,; the researcher met each patient individually to explain the purpose and the nature of the study in order to gain their cooperation before data collection.Data collection covered a period of 3 months starting from the first of April 2022 to the 30 June 2022.The days of interviews were four days a week during the morning shift from nine in the morning(9.00am)until one in the afternoon (1.00pm).
The structured questionnaire tool was used to assess the patients' characteristics, medical-health data history, and severity of CHF symptom, the degree of their resilience, and their health-related quality of life.

III. Administrative Design
Before beginning any phase of the study, the vice dean for post-graduate studies , researches and the dean of the nursing faculty provided formal consent to employ the study.This approval was delivered to the region of the study that was chosen for the study (El-Salam general hospital and Al-Nasr specialized hospital).To get permission to include the CHF outpatients in the current study, the directors of the aforementioned setting were approached and notified.After a concise and thorough description of the research's purpose and goals, CHF outpatients who participated in the trial also signed an agreement.The researcher also gave the responders the assurance that their replies would be kept private and that the data would only be utilized for legitimate scientific purposes.

IV. Ethical Considerations:
The following are some of the ethical research issues in this experiment: Before beginning the study, the Scientific Research Ethical Committee in the Faculty of Nursing at Port Said University gave its clearance.Before beginning the study, the hospital directors had to approve the research.The researcher made the participants aware of the study's objective and purpose.The confidentiality and maintenance of the subject data's anonymity were guaranteed to the researcher.Patients gave their informed permission and were given the option of participating or not in the trial.They also had the freedom to leave the study at any moment without facing any repercussions.

V. Statistical Design
The statistical design comprises the subsequent components: Coding of data is the process of assigning labels or categories to the information collected during research or analysis.The researcher encoded the data and formatted it in a way that was suitable for computer input.The statistical package for social science, commonly referred to as SPSS, version 20, was utilised to analyse the data.The study employed descriptive statistics to analyse the data.The qualitative data was evaluated using frequency and percentages, whereas the quantitative data was assessed using averages and standard deviation.The examination and interpretation of data using statistical methods.The Chi-square statistical test was employed to perform comparisons among categorical data.The chisquare test should be utilised when the expected count of cells with a value of less than 5 is greater than 20%.

RESULTS
The current study results showed that 30.6% of the studied patient aged from 50<60 years, 62.2% of them were male, and 79.6% of them were married.Also, 39.8% of them had 1<3 family members, 42.9% of them had a secondary stage, 60.2% of them did not have work.
Table (1) revealed that 80.6% of the studied patients had severe symptoms related to "pain" and "fatigue (tiredness) at its worst" also 77.5% of them had severe "disturbed sleep", 75.5 % of them had "shortness of breath" and 76.5 % of them had "feeling sad respectively .While 20.4% of them had moderate "a dry mouth at its worst" and 17.3% of them had mild "vomiting".8) demonstrated that, across all study patients , there was a statistically substantial negative correlation between overall resilience and symptom severity and interference.Furthermore, there was a statistically significant negative link between overall health-related quality of life and the intensity, interference, and number of patients investigated.The cases' overall health-related quality of life and resilience in general also showed a statistically significant favorable link.

DISCUSSION
Maintaining resilience and good health-related quality of life (HRQOL)was as important as survival to most patients living with congestive heart failure(CHF).Patients with congestive heart failure had markedly impaired resilience and HRQOL compared with other chronic diseases as well as healthy population.Resilience and health-related quality of life reflected the multidimensional impact of a clinical condition and its treatment on patients' daily lives.Patients with congestive heart failure experienced various physical and emotional distress symptoms.These symptoms limit patients' daily physical and social activities and result in low HRQOL (Naderi & Van Steenburg. 2018).
The present study revealed that patients were very or constantly bothered by their symptoms and These symptoms were found to interfere with patients' daily activities and their enjoyment of life.The symptoms reported by the patients in this study were also similar to those in previous studies conducted by Potka, Prokop, Migaj, Straburzyska-Migaj, and Grajek (2017) who reported that most of the patients with CHF had severe symptoms regarding chest pain and shortness of breath and The severity of symptoms depended on the body's ability to adjust to the decreased cardiac output.Initial signs and symptoms reflected the ventricle of the heart that was experiencing dysfunction.Also, their study which focused on the symptoms received a high prevalence rating, shortness of breath, Fatigue, and pain were the most common symptoms experienced by CHF patients.
The current study demonstrated that patients had positive resilience.Compared to the past, the majority of studied patients were more determined, competent, and accepted of their chronic illness (CHF) and current state of health.Their competence enabled them to maintain concentrate on their objectives, enhances their inner fortitude, and removed weakness.The current study was compatible with Movahedimoghadam et al., (2022), who found that improving resilience decreased the severity of shortness of breath and edema in patients who had CHF and led to a better life.In addition, the highest mean of participants' agreement was in handling situations calmly.This study was in the same line with Lee, Tung, Peng, Chen, Hsu & Huang. (2020), who found that the majority of participants agreed with handling their situations calmly and had competence .
The current study revealed that patients' health-related quality of life regarding physical activities was normal in usual mild daily activities and their disease doesn't affected by these mild activities such as bathing and dressing themselves.But the moderate and vigorous activities such as running, lifting heavy objects, participating in strenuous sports and walking more than 60 minute approximately wasn't as usual as daily activities performance because of congestive heart failure.Concerning general health related quality of life and compared to the general health, bodily pain was the most common cause that affected on health-related quality of life and general health .In general health, the current study revealed that patients with congestive heart failure and their perception to their general health was really affected according to the nature of their disease so they believed in their general health became lower than the past because of their age and the nature of their disease .according to their disease the patient had problems in their work and their regular daily activities especially in spending much more time in doing this activities which didn't take long time in the past and they had difficulty in performing their work or other activities most of time they described that as an extra effort.This might be due to that vigorous activities were restricted in cardiac patients due to fatigue and general weakness.Also, this might be due to that with time the human body coping mechanism decreased and the body became weaker than before.As well as this might be due to that work and activities required high efforts in which congestive heart failure patients not able to make high efforts.This study was compatible with Sygit et al., (2020), they revealed that their health compared to one year ago somewhat worse now than one year ago.Also This study was in the same line with Sygit et al., (2020), who revealed that regarding activities most of patients had limitations in vigorous activities, such as running, lifting heavy objects, participating in strenuous sports.Also this study was in the same line with Reddy et al., (2022), who reported that most of studied patients agreed with limitation of their work or other activities followed by spending much more time in doing activities than the past.Also this study was in the same line with Alisherovna et al., (2022), they revealed that most of studied patients agreed with their limitations in the work or other activities according to their disease.
The current study revealed that pain interfared with social activities such as normal work including both work outside the home and housework.Also physical health and emotional problems interfered with their normal social activities with family, friends and neighbors.While the emotional well-being gotten in the way of their social interactions such as going out with friends or family This might be due to that pain causes patient distress and fatigue which interfered with patients' normal work and this might be due to that congestive heart failure affected on patient's ability to engage in social interactions as a result of fatigue, discomfort and sometimes feelings of distress.This result was compatible with Perrotti et al., (2019) who revealed that bodily pain followed by physical health or emotional problems interfered with their normal social activities with family, friends, neighbors.Also this result was compatible with Mhesin et al., (2022), who reported that most of patients agreed with pain interfered with their normal work including both work outside the home and housework.Also this result was compatible with Davranovna et al., (2022), who reported that regarding social activities of studied patients most of them agreed with their expectations of their health get worse followed by their physical health or emotional health interfered with their social activities.
The current study indicated that the studied patient's most psychological status was feeling nervous that affected on their health-related quality of life and also they don't work on their activities carefully and usually took much more time than the past.But on other hand they felt calm and peaceful some of time this might be due to that congestive heart failure patients understood their condition well which helped them make better decision and feel better.This result was compatible with Freedland et al., (2021) who studied improving health-related quality of life in heart failure and reported that the majority of studied patients agreed with some of the time they feel calm and peaceful.In contrast with this result Heo et al., (2020) who studied prediction of heart failure symptoms and health-related quality of life at 12 months from baseline modifiable factors in patients with heart failure and reported that most of studied patients agreed with feeling as a very nervous person.
The current study showed that spiritual status especially the personal beliefs of studied patients gave them strength to face their difficulties and their disease.they thought slightly that their personal beliefs gave meaning to their life.this might be due to their spiritual and personal beliefs helped them in improving their health-related quality of life and influenced patients decisions and actions.This study was in the same line with Baert et al., (2018), who reported that the majority of studied patients agreed with their personal beliefs gave them strength to face their difficulties and disease.Also this study was compatible with Bahall et al., (2020), who studied health-related quality of life among patients with cardiac disease and revealed that the majority of studied patients agreed with their personal beliefs give meaning to their life.
As regard to relationship between the studied patients ' socio-demographic characteristics and total level of severity and interfering of their symptoms with patients healeh-related quality of life the current study illustrated that there were significant relation between severity and interfering of patient symptom and their age, sex and number of family.This might be due to that with older age the patient physiological processes, activity tolerance and compensation mechanisms decreased.This study was in the same line with Mhesin et al., (2022), who reported that the severity of symptoms interfering with patients health-related quality of life because of their old age physiological processes and their activity intolerance .
The current study showed that there was an opposite correlation between the severity of the symptoms and the patient's resilience, as the severity of symptoms interfered with their coping with their disease, which was called resilience.Also there was an opposite correlation between studied patient's severity of the symptoms and their health-related quality of life.In addition, that there was a positive correlation between the studied patients' resilience and their health-related quality of life.This might be due to that resilience improved patients coping strategies which improved patient's healthrelated quality of life.The current study also was in agreement with Kordestani, (2018), who revealed that resilience was positively correlated with patients' health-related quality of life the study results included a significant difference in health-related quality of life and its indicators among patients with congestive heart failure .Also, there was a significant difference between health-related quality of life, general health, physical health, psychological dimensions, There was a significant difference in psychological resilience among CHF patients and healthy individuals.This study was supported by Port Said Scientific Journal of Nursing Vol.11, No. 1, March 202420 Chow, (2021), who revealed that resilient patients may adopt more adaptive perceptions about their heart condition, which may help them adopt a more positive health behaviour, leading to better HRQOL

CONCLUSION
According to the results of the current investigation, it is often ended that: Across all patients assessed, there was a statistically significant negative association between overall resilience and the intensity and interference of the symptoms.
Furthermore, there was a statistically significant negative link between the interference and intensity of the symptom and the overall health-related quality of life of the research subjects'patients.Moreover, there was a statistically significant positive link between patients' overall health-related quality of life and overall resilience.

RECOMMENDATIONS
 Provide congestive heart failure patients with needed pamphlets, posters, and booklets, including instructions that contain information about disease therapy, diet schedule, medication, lifestyle changes, etc.
 Preparation of qualified nurses to increase awareness towards challenges that result from CHF for patients and their families through participation in specific educational courses that are related to health-related quality of life aspects.
 Developing and providing intervention programmes to enhance social support can lead to improved health-related quality of life for patients because of their longterm and chronic illnesses that affect their resilience.
 Follow up by Egypt health care authority hospitals in port-said governorate by tele-communication.

Table ( 2
) Displayed the frequency distribution of the examined patients according to level of resilience revealed that 41.8% of the studied patients were highly opposed to the statement "It's okay if there are people who don't like me."While 27.5% of the patients in the study disagreed with the statement "I usually manage one way or another," Concerning general health related quality of life and compared the general health, the highest mean was (2.983±.602)related to " bodily pain have you had during the previous period".While the lowest mean was (2.294± 1.931 & On other hand the lowest mean was "1.829±.026,2.153±.622,2.283±.581,2.376±.441&2.315±.592)respectively related to feel calm and peaceful, felt full of vitality, had a lot of energy, felt tired and been a happy person respectively.
lowest mean was (1.153±.304,1.254±.682,1.352±.783&1.783±.682 ) related to " Bathing or dressing yourself", " Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports", " Moderate activities, such as moving a table, pushing a vacuum cleaner, blowing, or playing golf" and " Walking more than a mile (60 minute approximately" respectively.Table (4)Showed that the highest mean was (3.431±1.884&3.172±.282)related to " pain interfere with your normal work (including both work outside the home and housework)?" and " physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups" repectively.While the lowest mean was (2.738±.012)related to " mental or emotional well-being gotten in the way of your social interactions (such as going out with friends or family, etc.)".Table (5)revealed that the highest mean was (2.752±.382,1.829±.026&1.793±.438)related to be a very nervous person, Didn't do work or other activities as carefully as usual and cut down the amount of time you spent on work or other activities" respectively.Table (7) illustrated that there were statistically significant relation between severity and interfering of patient symptom and their age.Also there were significant relation between severity and interfering of patient symptom and their sex and number of Table (